WP0040805 - Laserfiche WebLink

Home Browse Search

r r , DEPARTMENT U E ONLY Application Accep d By/�" Date // Z0l� Grout Inspe n By Date Pump Inspect on By I r2fp&4qj�r,da r f Data Sol[ Boring Inspect on By Date COMMENTS' WEL UMP ERMIT SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205.6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS G C ;.,5 T CrrYIZIP i`i-i __i'ia..vanr /3 �.ri [ ✓-u g9 4 rd - &I CROSS STREET � J Cs/ .: APNy(i � "`.�JU PARCEL SO:E'� LAND USE APPLICATION # D A n p r �^ Cp OWNER NAME PHONE �l:9�9'�e"-G�W7%�s�aA OWNER ADDRESS - ,.�� a Q "�'- B +' a CITY/STATE/ZIP ' a:Rj`�d�% d. $eF.c7�+sCF V `�.+�JZ° Received CONTRACTOR vu f lJE '�w� 'Y.� .5..';V C PHONE ( 20 9 . , cJ 2. ✓J'� Amount Date Permit! Invoice # Well ID# Remitted ryice Re ue t# _ �e� CONTRACTOR ADDRESS .d � � 41 �aL!1 C_d=N. 'e-5*t �`�' CITYISTATEiZIP .5o vezea e..0 fO O SUBCONTRACTQRtcoNs jLTANT PHONE SUBCONTRACTORICON LTANT ADDRESS CITYISTATEIgZI�P LICENSE " C-57 D C-61 D D-09 O Other NUMBER �cS ! EXPIRATION DATE BILLING PARTY: D OWNER D CONTRACTOR 0 SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMI IUNG: 0 General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) INTENDED USE I y o estic/Private D Irdgatlon/Agricultural D Industrial D Water Quality Monitoring O Soil Sampling/Characterization � ,a /' 0 Pu lie Water System WELL (PUMP PERMIT If d Terant from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK 0 Ne Y Well 0 Replacement Well 0 Well Alteration/Modification O Other 0 Me iftoring Well(s) # of wells ❑ Soil Boring(s) # or borings 0 Geolachnical # of bodngs O Ou -Of-Service Well 0 Out -Of -Service Well Renewal 0 Cross-Connectlon Repair - Ne Y Pump D Pump Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRU O Drilling Method ❑ Mu I Rotary O Air Rotary O Auger 0 Cable Tool ❑ Push Point 0 Other Proposed Weil Dep ft Excavation in diameter 0 Open Bottom O Gravel PacWGravel Size in diameter ❑ Co iductor Casing in diameter I Conductor Casing Depth ft Well Casing Diam ter _ in Thickness/Gauge/ASTM Schad 0 Steel D Plastic D Stainless Steel O Other ea Dept ft 0 Neat Cement (941b bag/5-10 gal water) 0 Sand Cement sack mW7 gal water Grout Sea, 0 Be itonite (20% solids) 0 Other Grout Placement Me od 0 Pumped 0 FrLre Fall 0 Other 0 Retardant I Accelerator (name) PEDESTAL . Instd led By 0 Driller KPump Contractor D Other ❑ Ca icrete Pedestal ODimensions: Width it Length ft Thick in 0 Christy Box O Stove Pipe PUMP Su mersible❑ Turbine ❑Other HP _T—_ Pump Set a,0 it Standing Water Level 13 it I HEREBY CERTIFY rHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY.ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACT VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENI ATION LAWS, MINIMUM HOUR A 1/ANCE NOTICE REQUIRED FOR INSPE T10NS - PLEASE CALL (209) 95 .76,9- SIGNED �- ri �'. _ 9iil TITLE DATE � �4� DEPARTMENT U E ONLY Application Accep d By/�" Date // Z0l� Grout Inspe n By Date Pump Inspect on By I r2fp&4qj�r,da r f Data Sol[ Boring Inspect on By Date COMMENTS' Area_ Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Codes Into Received Check#: tCash Amount Date Permit! Invoice # Well ID# Remitted ryice Re ue t# _ EHD x3-06 6111/2018 � ,a /' F � r �� WELL (PUMP PERMIT EENr veo 122020 NTANTy L tTMENT